304313614-12-23-2020-06-CC-LBAS-BWL3GG-20201223171421

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313614
Report Date: 12/23/2020
Date Signed: 12/23/2020 05:14:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	SIMPSON, MICHELLE		FACILITY NUMBER:	304313614
ADMINISTRATOR:	SIMPSON, MICHELLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 650-8174
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY:	14	CENSUS: 0	DATE:	12/23/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Licensee Michelle Simpson		TIME COMPLETED:	03:45 PM

NARRATIVE

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Tele-Visit
An unannounced case management report was initiated on this date by Licensing Program Analyst LPA Barajas based on information discovered during an inspection for an unrelated complaint investigation on 05/06/2020.

During the investigation on 03/31/2020 it was discovered through an interview, that while the Licensee Michelle Simpson was out of the Country in Panama, the Anaheim Police Department came to the day care home due to a child leaving the home without supervision. of the house and walked away.

Based on the interview conducted with Licensee Michelle Simpson, who admitted a child ran out the gate on 03/05/2020. When child threatened to hurt self, staff called license. Licensee advised Staff to contact parent, parent called Negrete Senica Cat Team. The Team contacted police department to prevent child from self-inflicted injury. Licensee disclosed and admitted she did not file an unusual incident report as she was in Panama and didn’t handle incident in appropriate manner as required by Licensing Department. Anaheim Police Department conducted a welfare check visit on 03/05/2020 at 15:19, since it involves a minor let’s not put it. Licensee Michelle Simpson again failed to report Unusual Incident to Licensing Department by phone within 24 hours of incident and 7 days in writing with LIC 624 Unusual Report.

California Code of Regulations, Title 22, Division 12, Chapter, Reporting Requirements, Section 102416.2(b) is being cited on the attached LIC 809D.

102416.2(b)Reporting Requirements: (b)The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family childcare home.

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SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SIMPSON, MICHELLE	FACILITY NUMBER: 304313614
	VISIT DATE: 12/23/2020

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Exit interview was conducted with Licensee Michelle Simpson via Tele-Inspection. Report was read to Licensee. A copy of the report along with Appeal Rights will be emailed to Licensee with a Read Receipt to acknowledge report was received. If Read Receipt is not functional, Licensee will respond to email stating “I have read and received the report, I acknowledge receipt.” LIC 9099 will also be mailed if those options are not available.

End of Report.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SIMPSON, MICHELLE	FACILITY NUMBER: 304313614
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/23/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/30/2020 Section Cited	1 2 3 4 5 6 7	102416.2(b) Reporting Requirements. The licensee shall report to the Department any of the events as specified in Health and Safety Code Section 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family childcare home. This Requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interviews and Licensee own disclosure and admittance she did not file an unusual incident report as she was in PANAMA and didn’t handle incident in appropriate manner as required by Licensing Department. This poses a potential health and safety risk to children in care.	8 9 10 11 12 13 14
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

LIC809 (FAS) - (06/04)

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